Chapter 2 General Inspection

General inspection is a series of accurate and meaningful observations. It includes a general survey of the patient’s sex, age, mental status, mood, posture, body movements, gait speech, breath odor, state of nutrition, stature, temperature and skin. General inspection begins with history taking.

General appearance

Even before the formal physical you will begin making observations that may alert you to disease. Throughout the history and physical, these cumulative observations form the basis for logical diagnostic deductions.

As the patient moves into the examining room, you might note the gait. Is it painful? Is there evident favoring of one side of the body, as in stroke?

A wealth of information can be gained by shaking hands with the patient. Warm, moist hands may suggest hyperthyroidism.

When the patient speaks, does the tone of his voice suggest the hoarseness of laryngeal cancer, the weakened, thickened, and lowered voice of hypothyroidism; the “vocal ataxia” or “scanning speech” of multiple sclerosis or cerebellar disease?

The face has always been the mirror or the mind. It shows pain, fear, anxiety, and sadness. It is in the face that we first notice whether our patients are pale, ruddy, cyanotic, or icteric. Thickened features suggest hormonal imbalance-e.g., of the thyroid or growth hormone. Fullness may be a consequence of edema, obesity, or a result of excess corticosteroids. A malar flush may signal lupus or mitral stenosis. Shiny skin and tight features first alert us to possible scleroderma. Cranial nerve dysfunction may be manifested by ptosis, strabismus, or facial asymmetry.

Habitus refers to your patient’s general shape-his or her body build. Cachexia is an extreme thinness and debility caused by some serious disease, such as cancer or chronic infection. Signs of recent weight loss, such as loose clothes, newly punched belt holes, and redundant skin folds, clue the clinician to a loss of flesh or fat that may or may not have been noticed by the patient.

Simple obesity is a deposition of body fat in excess of some arbitrary standard. Pathologic obesity is deposition of body fat to the point of physiologic compromise of the individual, who may have respiratory, cardiac, or orthopedic difficulty. In these conditions excess fat is apportioned generally around the body-face, trunk, buttocks, and extremities. Deposition of fat around the trunk, with thin extremities in which muscle wasting is evident, may suggest hypercorticosteroidism.

Vital Signs

Because a heartbeat, breathing, and body warmth are the clinical signs of life (the absence of which signaled death in the era before the advent of modern laboratory aids such as the electroencephalogram), the so-called vital signs (pulse, respiratory rate, temperature, and blood pressure) continue to be the most frequently examined of all physical findings.

Temperature

The temperature is generally taken by placing the thermometer under the patient’s tongue for 3 minutes. The temperature may be taken orally or rectally, and in the United States the Fahrenheit scale is usually used. Falsely low levels may result from incomplete closure of the mouth, breathing through the mouth, leaving the thermometer in place for too short a time, or the recent ingestion of cold substances. Falsely elevated levels may result from inadequate shaking down of the thermometer, previous ingestion of warm substances, smoking, recent strenuous activity, or even a very warm bath.

In most persons there is a diurnal (occurring every day) variation in body temperature of 0.3~1C. The lowest ebb is reached during sleep, at which time the temperature may fall as low as 35.7~36.1C. As the patient begins to awaken, the temperature slowly rises.

You will note that the upper limit of normal on the standard thermometer is 37C.

Rectal temperatures are usually 0.3 to 0.5C higher than oral temperatures, but they tend to be less subject to alteration by the oral factors mentioned above and are generally more constant and reproducible.

Pulse

The radial pulse is best taken at the base of the patient’s thumb. If the examiner uses two of three fingers along the course of the artery, he or she may determine the pulse contour as well as the rate.

Initially, and always if the pulse is irregular, the examiner should count the pulse for a full 60 seconds. If the pulse rate is between 60 and 100, and the rhythm is absolutely regular, many physicians will “shortcut” and count the pulse for 30 seconds, then multiply by two.

If the radial pulse is poor or irregular, the pulse may be taken by listening to or palpating the apex of the heart (the apical pulse). The normal resting pulse rate ranges from 60 to 100. It may b in the 50 in a conditioned athlete, or 100 or over in an excited patient. Rates less than 60 are often referred to as bradycardia, and rates over 100 as tachycardia.

The pulse rate and rhythm should be recorded, and if abnormal contour is discovered, that too must be noted.

Respirations

Many physicians find it of value to count the respirations while appearing to take the pulse, since the natural tendency of the patient is to breathe awkwardly under observation. Normal respiratory rate is between 8 and 14 per minute in adults and is somewhat more rapid in children.

Note abnormalities of respiratory rate and rhythm. Extremely slow respiration usually indicates central nervous system respiratory depression due to disease or drugs. Periodic or Cheyne-Stokes respiration occurs with serious cardiopulmonary or cerebral disorders. Deep slow breathing (Kussmaul’s respiration) characterizes acidosis, a state in which the physiologic response to increased metabolic acid in the blood is a compensatory “blowing off” of carbon dioxide. Extreme tachypnea is present during many acute illnesses. It may be due to chronic or acute pulmonary or cardiac disease or systemic disorders, such as shock, severe pain, and acidosis; although it may represent undue excitement or nervousness, especially when accompanied with sighing, an organic cause should be excluded.

The patient’s preferred position is important. Can he lie flat comfortable? Patients with congestive heart failure prefer the sitting position, as do patients with pulmonary disease during acute attacks of infection or bronchospasm. Patients with pericarditis often sit and lean forward.

The normal adult blood pressure varies over a wide range. The normal systolic range varies from 95 to 140 mm Hg, generally increasing with age. The normal diastolic range is from 60 to 90 mm Hg. Pulse pressure is the difference between the systolic and diastolic pressure. Mean pressure can be approximated by dividing the pulse pressure by three and adding the value to the diastolic pressure. Routing measurements should be made with the patient sitting and recumbent.